Form Tr-7000 - Court / Dor Financial Statement
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1Case Number: ________________________
(Numero de su caso)
Sentence Date: ________________________
(Fecha de sentencia)
COURT / DOR FINANCIAL STATEMENT
(Corte / DOR Reporte de Estado Financiero)
1.
General Information
SELF
)
SPOUSE
(sugo
(esposo/esposa)
(Informacion general)
a. Name:
______________________________
____________________________
(Nombre)
b. Address:
______________________________
____________________________
(Domicillio)
City, State, Zip
______________________________
____________________________
(ciudad, estado, codigo postal)
c. Telephone Number:
(_____) _______________________
(_____) _____________________
(numero de su telefono)
d. Date of Birth:
______________________________
____________________________
(fecha de nacimiento)
e. Social Security Number:
______________________________
____________________________
(numero de su seguro social)
f. Driver’s License Number:
__________________State:_______
__________________State:______
(numero de su licencia de manejar)
g. Automobiles Owned:
______________________________
____________________________
(automobile de su propriedad)
Make
Model
Make
Model
(marca)
(modelo)
(marca)
(modelo)
______________________________
____________________________
Year
License No. / ST
Year
License No. / ST
(ano)
(licencia/estado)
(ano)
(licencia/estado)
2.
Dependents in household under age 18: ________________________________________________________
(cuantos dependientes en su hogar menores de 18 anos)
3.
List Banking Information:
(informacion lista de sus bancos)
Branch:
Bank Name:
Account No.:
(rama)
(nombre del banco)
(numero de cuenta)
CHECKING:
SAVINGS:
___________________
)
_____________________
_______________________
(CHEQUES
(AHORROS)
CHECKING:
SAVINGS:
___________________
_________________
____________________
)
(CHEQUES
(AHORROS)
CHECKING:
SAVINGS:
___________________
_________________
____________________
)
(CHEQUES
(AHORROS)
4.
Employment Information:
(Informacion lista de sus trabajo)
a. Employer’s Name:
______________________________
____________________________
(en donde trabaja)
b. Employer’s Address:
______________________________
____________________________
(direccion de su empleado)
City, ST Zip
______________________________
____________________________
(ciudad, estado, codigo postal)
c. Telephone Number:
(_____) _______________________
(_____) _____________________
(numero de su telefono)
d. Salary before taxes:
$_____________________________
$___________________________
(salario untes de impuestos)
5.
Nearest Relative (not living with you):
(miembro de su familia mas cercana:que no vive con usted)
Name: ______________________________
Address: ____________________________________________
(nombre)
(domicilio)
Telephone Number : (____)______________
City, State, Zip: _______________________________________
(numero de telefono)
(ciudad, estado, codigo postal)
__________________________________________________
Signature
Date
(firma)
(fecha)
TR-7000 REV. 10/04
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